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Patel's disturbing record
at
Kaiser
Despite a series of malpractice cases and negligent
surgeries, Kaiser Permanente saw Dr. Jayant Patel as a moneymaker.
Sunday,
November 06, 2005
SUSAN GOLDSMITH and DON COLBURN
The Oregonian

Dr. Jayant M. Patel was a surgical star.

Just three years after he was hired by Kaiser
Permanente Northwest in
1989, the HMO gave him the job of training its young surgeons.

Patel gravitated to the toughest cases, confidently
rebuilding colons
and removing tumors to become one of Kaiser's busiest surgeons. In
1995,
fellow Kaiser doctors voted him a "Distinguished Physician of the
Year."

But there was another side to Patel's work, one
hidden from both his
patients and many colleagues.

By the time Kaiser honored Patel, he had been
involved in a string of
problem cases, eight of which had prompted or would lead to malpractice
or wrongful death lawsuits, an investigation by The Oregonian has
found.

In four of those problem cases, Patel's patients
died. One young man
was left impotent. An elderly woman lost a kidney and became
incontinent.
Yet it took Kaiser until 1998 to begin investigating Patel and five
more
months to bar him from surgeries on the liver, pancreas and colon.
State
medical regulators did not discipline him until 2000.

Between the time Kaiser lauded Patel and the time it
restricted him,
he performed scores of operations -- including one in which an elderly
patient bled to death after Patel severed an artery and vein during
pancreatic
surgery.

Patel resigned from Kaiser in 2001 and later
surfaced at a hospital
in Australia, where authorities are investigating his role in 13
patients'
deaths and asking how he got the job given his troubled background.

But Patel also slipped through the cracks in
Oregon's largely secretive
system for spotting and disciplining problem doctors, The Oregonian
found
in reviewing his 12 years at Kaiser. His case highlights how hard it
can
be for patients to learn about a physician's track record -- and the
risks
that come with not knowing.

Because of confidentiality laws, patients have
little opportunity to
learn if their doctor is under investigation by a hospital or
regulators.
Patel's case also exposes deficiencies in a state law requiring
insurers
to report malpractice claims, which regulators screen for possible
negligence.
Kaiser asserts it is exempt from the law, although state regulators
disagree.
It did not report claims against Patel or its other doctors from 1991
to
2004.

Between 1994 and 1998, The Oregonian found, Kaiser
settled five Patel
cases and paid out $1.8 million in two of them. Those claims, had they
been reported, would have triggered an investigation of Patel by the
Oregon
Board of Medical Examiners years earlier, said Executive Director
Kathleen
Haley.

Kaiser is the region's largest health maintenance
organization, with
a health plan covering 470,000 people in Oregon and Southwest
Washington.
The nonprofit defends its handling of Patel and said it has tightened
procedures
for tracking medical errors. A situation like Patel's would be
discovered
and corrected sooner now, Kaiser maintains.

The HMO acknowledged that Patel had been sued more
frequently than other
Kaiser doctors. Kaiser would not discuss those cases. It denied the
allegations
in court and moved to have Patel dismissed as a defendant.

"It's important to note that Kaiser Permanente's
patient safety program
doesn't hinge on waiting for someone to file a claim," Kaiser said in a
prepared statement to The Oregonian. "We actively monitor for a long
list
of signs that might indicate a problem."

Now back in Portland, Patel, 55, has declined
repeated interview requests
through his lawyer, Stephen Houze. He faces possible criminal charges
in
Queensland, Australia, where he had landed the job as chief surgeon at
Bundaberg Base Hospital with the help of six enthusiastic letters of
introduction
written by fellow Kaiser doctors.

"I can recommend Dr. Patel without any reservations
whatsoever," wrote
Dr. Edward Ariniello, Kaiser's former chief of surgery who hired Patel
and, later, sat on the committee that restricted Patel's practice.

Ariniello did not respond to requests for comment.
It is not clear how
much the other doctors recommending Patel knew of his record; none
would
discuss the matter. Nor would most of the more than two dozen other
physicians
and nurses who worked with Patel at Portland hospitals and were
contacted
by The Oregonian.

The former chairman of the Michigan Board of
Medicine, whom The Oregonian
hired to examine medical records from Patel's patients, said his
succession
of bad outcomes should have prompted a review years earlier.

"As soon as you see one or two, you say, 'We better
take a look,' "
said Dr. Norman Bolton, who was chief of surgery at Sinai Hospital in
Detroit.
He called one 1995 case, in which Patel supervised a routine hernia
operation
where an unrelated vein was cut by mistake, "grotesque" and a "red
flag."

"Certainly a result such as this should have called
for an evaluation
of the operating surgeon," Bolton said.

But it didn't -- for years.

Promise hid a troubled past

Patel arrived in Oregon from Buffalo, N.Y., in 1989
with a strong resume
and rave reviews. A native of India, the 39-year-old Patel had
completed
medical school and early surgical training by 1977 before emigrating.

He had finished his surgical residency, taught
surgery for five years
and run the residency program at a prominent Buffalo hospital. He
contributed
to a medical textbook and published numerous articles with Dr. Raymond
Hinshaw, a nationally known Rochester surgeon who praised him in
recommendation
letters.

At Kaiser, Patel built a reputation as
knowledgeable, aggressive and
brash.

"He boasted a lot about his surgical abilities,"
said Dr. Gerald Holguin,
Kaiser's chief of anesthesiology from 1993 through 1999. "He was
arrogant
and full of himself, but there was a charming side to the man."

Patel and his wife, Kishoree, a Kaiser internist,
settled into a sprawling
Beaverton home they purchased for $420,000 in 1991. And while keeping a
busy practice at Bess Kaiser Medical Center, Patel took on extra
duties,
running Kaiser's surgical residency program at Legacy Emanuel Hospital
& Health Center and volunteering to screen fellow surgeons for
national
certification.

"He was very well liked," said Dr. Robert McFarlane,
a retired Kaiser
surgeon who worked with Patel on administrative matters. As a surgeon,
McFarlane said, Patel was hard-working and "pretty aggressive,"
preferring
such technically demanding operations as liver surgery and intestinal
reconstruction.

He showed little interest in learning the new
technique of laparoscopic
surgery that emerged in the mid-1990s as a way to do abdominal
surgeries
with smaller incisions and less chance of infection, McFarlane said.
"That
effectively eliminated him from doing a lot of routine surgeries, like
gallbladder," he said.

In late 1996, Bess Kaiser Medical Center closed.
Patel then began operating
on Kaiser patients at Providence St. Vincent Medical Center, where he
brought
a reputation as an articulate, knowledgeable and prolific surgeon -- "a
go-to guy for major surgery" -- said Dr. Roger Alberty, St. Vincent's
chief
of surgery.

What neither Alberty nor Kaiser knew was that Patel
had a disturbing
secret in his past.

Kaiser never checked Patel's disciplinary record in
New York when it
hired him, the HMO told The Oregonian. And it turned out that Patel
omitted
an important detail.

In 1981, the University of Rochester dismissed Patel
from its surgical
residency program after patients accused him of altering records to
make
it seem as though he'd examined them when he had not. Patel entered
data
on five patients' charts without examining them and tried to coerce a
patient
into not cooperating with investigators, according to a statement of
charges
from the New York medical licensing board.

The board found Patel guilty of professional
misconduct, fined him $5,000
and put him on three years' probation, which passed before he completed
his residency in Buffalo.

The Oregon Board of Medical Examiners was aware of
the misconduct finding
but granted Patel a license in 1989 based partly on an enthusiastic
recommendation
from Hinshaw. In retrospect, Patel's problems in New York foreshadowed
a pattern that played out over the next decade in Oregon and, later, in
Australia.

Slipshod medical practice. A fudged resume. And
disciplinary sanctions
that went unnoticed.

A pattern of problems

The year after his arrival at Kaiser, Patel
performed hernia surgery
on a patient who claimed in a subsequent lawsuit that he'd been left
sterile.
Although the case was dismissed for procedural reasons, others like it
soon followed.

In 1992, Patel and a resident he supervised operated
on a 28-year-old
man with ulcerative colitis, a severe bowel irritation. Residents, or
young
doctors in training, typically assisted Patel in the operating room and
worked under his direct supervision.

The operation was to fashion a new colon for the
patient, using his
stomach lining. According to a 1993 lawsuit in Multnomah County, the
doctors
severed the urethra, the tube through which urine passes from the
bladder.
A few weeks after the operation, the patient said he began urinating
from
his rectum.

The patient, a restaurant cook who grew up in
Portland, asked that his
name not be used because the surgery and complications made him
permanently
impotent. He settled with Kaiser for more than $100,000 in 1994, two
years
into Patel's tenure as director of surgical residents.

The amount of the settlement is significant because
the state medical
board normally would investigate any malpractice payout of $100,000 or
more.

In 1993, an error by Patel led to what Bolton, the
surgeon hired by
The Oregonian, called a "real tragedy."

Eighteen-year-old Ronela Tepei, a Romanian
immigrant, came to Patel
with abdominal pain and a family history of polyposis, a predisposition
to colon cancer. Her father had died of colon cancer that spread to his
pancreas two years earlier at 42, according to Tepei's mother, Tabitha
Starkenburg. Tepei's uncle had died of the same cancer at 19.

Patel ordered a sigmoidoscopy, a test that can
detect abnormalities
in the lower colon. When Tepei's results came back normal, Patel told
her
she was healthy, according to Starkenburg, and medical records reviewed
by Bolton.

The problem, Bolton said, is that a sigmoidoscopy
was the wrong diagnostic
procedure for a patient with Tepei's history. The standard was to order
a colonoscopy, he said, a more extensive screening that examines the
entire
colon for the kind of polyps that are the first sign of cancer.

In younger patients, Bolton said, it's critically
important to screen
the entire colon because the polyps turn cancerous quickly. If polyps
are
detected, the patient's colon can be removed to prevent cancer from
developing.

That never happened to Tepei. In 1995, while no
longer a Kaiser patient,
she died of colon cancer that had spread to her lungs and liver. She
left
behind a husband and an infant son.

Starkenburg blames Patel: "You can make a mistake,
but I think he's
responsible for my daughter's death."

After reviewing Tepei's records, Bolton agreed. Her
death "is one you
can point to that should not have happened," he said. "Had she gotten a
colonoscopy, there was a darn good chance she would have lived."

In 1994, Patel removed part of Leatrice Fairchild's
stomach because
of ulcers. Fairchild's surgical wound came apart, causing infections
and
leakage that doctors could not control. She died two months later.

Patel missed the leak, Bolton said, though he noted
that Fairchild's
case was complex because she was extremely obese and her ulcer was
large.
Fairchild's family sued, and Kaiser later settled for $375,000.

Then, in 1995, three cases came along that would
lead to lawsuits and
settlements.

Three weeks after Patel operated on Gerald Tucker's
inflamed pancreas
in February, the 50-year-old died from massive internal bleeding and
infection
that had required three corrective surgeries, his medical records show.

Bolton, after examining the records, said that while
Tucker's death
does not necessarily reflect poorly on Patel's technique, it suggests a
worrisome pattern that Kaiser should have noticed in the context of
other
bad outcomes. Kaiser settled the Tucker family's wrongful death lawsuit
in 1999 for $900,000.

During gastrointestinal surgery in September 1995,
Patel accidentally
cut the ureter of a 79-year-old woman. Dr. Sanjeev Sharma, a medical
resident
in the operating room with Patel that day, described it as "awful." The
ureter is a tube that links the kidneys to the bladder.

"I tried very hard to get him to realize there was a
problem after the
surgery," said Sharma, now a cardiothoracic surgeon in Stockton, Calif.
The patient, Helen Brooks, "was leaking urine."

"I spoke up about Mrs. Brooks to Patel, and he said,
'It's OK, it's
OK,' " Sharma told The Oregonian.

But it wasn't OK. Brooks' lawsuit said she became
incontinent for three
months, underwent three further surgeries and lost a kidney. She
settled
with Kaiser confidentially in 1997 and died the next year. Brooks'
lawyer
said he did not know whether her death was related to the operation.

On the same day as Brooks' surgery, Susan Tomberlin
was on Patel's schedule
for an outpatient hernia repair.

Tomberlin, then an unemployed data entry clerk, said
she was in her
hospital bed recovering when a nurse confided to her that something had
gone wrong.

During the operation, the femoral vein from
Tomberlin's right leg was
inadvertently damaged, then deliberately severed so Patel could attempt
a repair. Afterward, a potentially life-threatening clot developed.

Patel was supervising a resident during the surgery,
but said in a sworn
legal deposition later that he was responsible. Bolton described what
happened
as "grotesque." He said the severed vein was so far removed from the
surgical
area that cutting it isn't even considered a risk.

"It's almost impossible for me to think of a
rationale that would allow
this kind of complication to occur," Bolton said. "He was operating
below
where he should be. It's a big vein. Even when you repair it, the
repairs
don't do so well. She's in for a lifetime of trouble."

Tomberlin said she couldn't walk or pull on pants
for six months because
of excruciating pain. Kaiser settled her medical negligence case
confidentially
in 1997.

"When I saw another doctor, he said I was a walking
time bomb from this.
They said this could kill you if a piece of this blood clot gets
loose,"
said Tomberlin. "When I mentioned that to Dr. Patel, he screamed at me
like I was a 2-year-old and told me I wasn't to talk to anybody about
what
happened."

One doctor speaks up

Susan Tomberlin's case would have triggered an
immediate review of the
responsible surgeon at his hospital, Bolton said, especially with
evidence
of recurring problems in routine and complex surgeries.

Yet Kaiser didn't start its investigation of Patel
for more than two
years.

Kaiser said fellow surgeons began raising questions
about Patel sometime
in late 1997, but officials declined to be more specific. Though Patel
"was the target of lawsuits more frequently than his fellow surgeons at
Kaiser Permanente," the lawsuits did not trigger the practice review,
Kaiser
said. The HMO looked at outcomes in a sample of 79 Patel surgeries,
most
of them not problematic, before restricting him in June 1998.

Since 2000, Kaiser officials said, surgical outcomes
are tracked by
computers, and medical staff can complain anonymously through a
national
hot line. But during the 1990s, quality assurance largely depended on
patients'
complaints or doctors coming forward to report their own mistakes,
Kaiser
spokesman Larry Wheeler said.

"Without the rigor of today's systems, I suspect
things happened that
didn't hit the radar as quickly as they do today," Wheeler told The
Oregonian.

The first blips might have been at Providence St.
Vincent, where Patel's
practice shifted after Bess Kaiser shuttered.

That is where Dr. Sally Ehlers spoke up.

Ehlers, now a general surgeon in Centralia, Wash.,
was a resident under
Patel for three years. Ehlers said she had many concerns about Patel --
she described him as sloppy, arrogant and uncaring -- but worried that
her own job could be on the line if she criticized Patel.

"If I had someone to complain to, I would have
started complaining,"
she said. "But I didn't."

That changed when Patel stopped overseeing residents
under a reorganization.
In summer 1996, Ehlers, then at St. Vincent, decided to come forward
about
a patient whose care had troubled her for years.

The patient, Duane Feakin of Scappoose, had his
colon removed by Patel
in 1992 for ulcerative colitis. Infections and other problems forced
several
additional surgeries; in 1994, Feakin was hospitalized for 49 days.

Ehlers said a pathology report in 1996 indicated
Feakin had Crohn's
disease, which has similar symptoms to ulcerative colitis but sometimes
can be treated without surgery. She said Feakin never should have had
his
colon removed and that Patel missed signals pointing to a diagnosis of
Crohn's.

Ehlers said she warned Feakin that year to get away
from Patel, and
Feakin dropped him. Feakin confirmed the account to The Oregonian,
provided
his medical records, and gave Ehlers permission to discuss his case.

At a weekly, confidential meeting among St. Vincent
doctors to discuss
problem surgeries, Ehlers offered Feakin's case for discussion. She
said
the other surgeons were surprised. Later on, "Dr. Patel became very
hostile
and aggressive toward me," Ehlers said. "He knew I presented the case."

Ehlers believes the meeting was the first red flag
for Alberty, the
St. Vincent chief of surgery, who told The Oregonian his hospital began
looking at Patel's record sometime afterward and well before Kaiser
began
its review.

St. Vincent evaluators first assumed Patel's high
rate of complications
arose from the difficult cases he tackled, Alberty said. But then a
pattern
emerged: clear problems with upper abdominal surgery involving the
liver,
pancreas and bile duct. Technical skill was not Patel's problem,
Alberty
said. Rather, it was poor judgment or carelessness.

"We weren't sure which -- maybe it was a
combination, we didn't know,"
Alberty said. "But he didn't seem to understand he was getting into
trouble
on these big cases. . . . Things weren't matching up to our other major
surgeons doing this kind of surgery."

While suspicions grew at Providence St. Vincent,
Patel continued to
operate.

Bolton, who examined Mesecher's records, said such
cases are inherently
risky. The 73-year-old's tumor involved a critical vein and artery, and
the operation shouldn't go forward until the surgeon is certain the
cancer
can be safely cut away. But in this case, Bolton said, the records show
Patel committed too soon.

"He went right ahead and started cutting things --
until he saw the
damage," Bolton said, calling it a clear case of malpractice. "This is
very complicated surgery, but he did a really rotten job."

Mesecher bled so profusely that doctors had to give
her more than three
times her blood supply. A post-surgery report said blood "was pooling
off
the bed and onto the floor." Mesecher died that afternoon.

"We asked lots of people if (Patel) knew what he was
doing at Kaiser
and St. Vincent and were told he was a specialist and was great," said
Mesecher's daughter, Sandra Ickert.

"I feel like I was lied to by a bunch of people."

Records kept confidential

Patients like Mesecher have no way to know if their
doctor's competence
is under review -- unless an insider like Ehlers divulges it.

In Oregon and other states, any information a
hospital has on a doctor's
performance, surgical mishaps or internal investigations is
confidential
by law. It cannot be disclosed, even in a court case. Investigations by
the Oregon Board of Medical Examiners also are confidential until the
board
issues a formal complaint.

"It's easier to find out about your roofer or your
lawyer than your
doctor," said Greg Smith, a former intensive care nurse turned
malpractice
attorney in Salem.

State law requires any doctor who has information
about another doctor's
possible incompetence to inform the medical board within 10 working
days.
But only 8 percent of all new medical board investigations last year
were
the result of complaints by health care providers, including doctors.

Kaiser kept its own doctors in the dark about Patel,
including some
of those who later wrote the recommendation letters he sent to
Australia.

"Most of the physicians who wrote the letters would
not have known about
corrective actions taken up to that point against Patel," Kaiser said
in
its statement to The Oregonian. "Such corrective actions are usually
handled
by a limited number of people directly charged with managing and
monitoring
a physician's performance."

Kaiser's practice review of Patel took five months.
On June 25, 1998,
the HMO banned him from pancreas and liver surgeries and colon
reconstructions.
Kaiser also required Patel to get a second opinion before any difficult
surgery and said he must take classes on communication skills and
preventing
malpractice losses.

At that point, Kaiser reported its disciplinary
action to the state
board and the National Practitioner Data Bank, a confidential database
available for licensing boards and hospitals to check a physician's
background.

Kaiser insists that it acted responsibly in Patel's
case. "We were the
ones who did something," Dr. Maureen Wright, who oversees physician
competence
at Kaiser, told The Oregonian in May.

In its September statement to The Oregonian, Kaiser
revealed more detail
about Patel's departure, saying its physician group put him on
probation
in September 1999 after "instances of poor communication with
patients."
By late 2000, after the state board sanctioned him, Patel "was
essentially
no longer doing inpatient surgeries," the statement said.

Patel took a leave of absence from Kaiser in
February 2001, then submitted
his resignation on June 20.

Kaiser said the medical group's board was scheduled
to discuss firing
him the next day.

International scandal

The furor in Australia surfaced last April. An
Indian surgeon from Oregon
-- "Dr. Death" in the Aussie media -- had botched scores of surgeries.
Patients died, their stories sometimes gruesome.

In 2003, Patel had landed as surgical director of
Bundaberg Base Hospital
in Queensland after hiding his past.

His resume said he left Kaiser a year later than he
actually did. Australian
investigators found that he lied twice on his medical license
application,
indicating he'd never been disciplined. And he failed to submit the
part
of his Oregon license stating he'd been restricted from doing some
types
of surgery.

As questions mounted, Patel hurriedly resigned and
returned to Portland.

An Australian commission investigating him has yet
to issue its final
report but said in July it will recommend charging Patel with murder or
manslaughter in at least one case. Of 13 Patel patients who died from
substandard
care, investigators said, eight had operations Patel was restricted
from
performing in Oregon.

Anthony Morris, the commission's former chairman,
issued a scathing
report on "the Patel phenomenon" in September, noting that Queensland
authorities
were partly to blame for inadequately checking Patel's record. Among
other
things, the report said Patel performed unnecessary operations, removed
wrong organs, sewed wounds that repeatedly burst or leaked and
frequently
misrepresented his patients' progress.

Morris pondered how Patel could have lasted as a
chief of surgery for
two years.

"Paradoxically, the very fact that Patel was not
totally incompetent
only added to his lethal propensities," Morris wrote. "A surgeon who
was
obviously incompetent would not have lasted so long, or done so much
harm,
in the position to which Patel was appointed."

In Portland, some who crossed Patel's path wonder
what might be different
if they had known more about his competence.

"It's upsetting that he got away with this kind of
practice for so many
years," said Paula Tucker, whose husband died after pancreatic surgery
by Patel. "It wasn't a choice my husband had."

Vickie Boyle had her colon removed by Patel in 1995
and later ended
up rehospitalized for infection and a perforated bowel. When she
questioned
Patel about what happened, he asked if she'd been "eating toothpicks."